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Women's Health > Preterm labour > Flashcards

Preterm labour Flashcards

1
Q

What is term?

A

Period between 37-42 completed weeks of gestation

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2
Q

What is post term?

A

Strictly period after 42 weeks gestation

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3
Q

preterm?

A

Period between 23-36 completed weeks of gestation

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4
Q

What is human preterm labour generally defined as?

A

Presence of uterine contractions and progressive cervical effacement and dilation occurring between 23-36 completed weeks of gestation

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5
Q

What is important to consider as well as gestation length in preterm labour?

A

Birthweight; often increases parallel with gestation length but pathological situations may change relationship.

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6
Q

What is the normal birthweight for a term infant?

A

2500 - 4000g; mean 3250g

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7
Q

Why is estimated date of confinement essential?

A

To allow reliable subsequent determination of normality of gestation length and birthweight

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8
Q

What are the conditions which may contribute to preterm labour? (have etiological association)

A
  • Previous preterm birth
  • PPROM
  • APH (esp abruption)
  • Uterine overdistension
  • cervical insufficiency
  • Infection: genital tract or abdominopelvic structures; systemic (flu)
  • Foetal abnormality
  • Uterine abnormality: congenital, fibroids
  • Placental insufficiency: PET, maternal disease (renal, autoimmune, thombophilia)
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9
Q

When does uterine over distension occur?

A

Polyhydramnios and multiple gestations

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10
Q

What are the pathogens which commonly infect the genital tract and trigger preterm labour?

A
  • Chlamydia
  • Listeria monocytogenes
  • GBS
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11
Q

What uterine abnormalities may precipitate pre term labour?

A
  • incomplete Mullerian duplications (e.g. subseptate uterus)

- cervical incompetence

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12
Q

What are the environmental / social causes of pre term labour?

A
  • Tobacco / smoking
  • Illicit drugs (coke, crack)
  • Sexual activity (weak)
  • Exercise (weak if reasonable exercise)
  • Stress (weak)
  • Employment (weak)
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13
Q

Presentation preterm labour?

A
  • Increase in uterine contractions
  • Sudden loss of clear fluid (i.e. membrane rupture)
  • Sudden increase in vaginal discharge
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14
Q

How is preterm labour diagnosed?

A
  • Hx: contraction details, EDD
  • PEx: sterile spec, exclude ROM, progressive cervical effacement and dilation
  • Ix: foetal fibronectin, amnisure
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15
Q

Why is a sterile speculum exam conducted in suspected preterm labour?

A
  • Check for cervical changes
  • Check for ruptured membranes
  • Exclude cord prolapse
  • allow micro swab of cervix, amnisure if required
  • abdo palpation of uterus for contractions
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16
Q

Initial management of preterm labour?

A
  • Confirm diagnosis
  • Aetiology and Rx if appropriate
  • Tocolysis (nifed)
  • Admit to perinatal centre with appropriate facilities; neonatal team aware
  • Observe (hours) and assess for cervical change
  • Foetal fibronectin swab
  • Consider: CST and MgSO4, GBS prophylaxis
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17
Q

What is foetal fibronectin?

A

Choriodecidual glycoprotein released into the vagina at a preclinical stage of preterm labour

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18
Q

What must be decided once preterm labour diagnosed?

A

Advisability of tocolytic therapy

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19
Q

Contraindications to IV salbutamol in preterm labour tocolysis?

A
  • Diabetes (causes hyperglycemia)
  • maternal cardiac disease (tacky)
  • APH (subverts normal CV homestatic mechanisms)
  • ROM (age dependent; risk of chorioamnionitis outweigh benefit)
  • Cervical dilation >4cm
  • Genital tract infection
  • FDIU or abnormality incompatible with life
  • Foetal distress
  • Gestation >32w
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20
Q

Why is tocolysis contraindicated with cervical dilation >4cm?

A

Tocolysis ineffective by that stage

21
Q

What is the current drug of choice as a tocolytic?

A

Nifedipine PO

22
Q

Why can’t IV salbutamol and PO nifedipine be given together?

A

CV side effects: hypotension, tachycardia, palpitations

23
Q

What are the options for tocolysis?

A
  • Nifedipine
  • Salbutamol
  • Indomethacin (PG synthesis inhibitor)
  • Atosiban (oxytocin receptor antagonist)
24
Q

What is the main utility of tocolysis given their disappointing effect on perinatal outcomes?

A
  • 1) Maintaining uterine quiescence during transfer of a patient in preterm labour
  • 2) Maintaining foetus in utero for 24-48h to allow medications for foetal lung development
25
Q

How may the incidence of neonatal respiratory distress be dramatically reduced?

A

Corticosteroids given maternally 24-48h prior to delivery between 26-32 weeks gestation

26
Q

Why are corticosteroids effective in reducing neonatal respiratory distress?

A

Cross placenta and trigger production of lung surfactant in the foetus

27
Q

What other conditions are improved by the maternal administration of corticosteroids?

A
  • necrotising enterocolitis

- intraventricular haemorrhage

28
Q

How is incidence of CP reduced?

A

Magnesium sulphate administered IV to mother at risk of early preterm

29
Q

Foetal factors to consider in mode of delivery in preterm labour?

A

Foetal

  • number
  • normality
  • presentation
  • distress
30
Q

Why do premature foetuses presenting breech usually require C section?

A

Increased risk of hypoxia due to cord prolapse and/or cervical entrapment of foetal head in an incompletely dilated cervix

31
Q

When do membranes usually rupture?

A

Rupture during labour at end of first stage or beginning of second

32
Q

Why is PROM managed differently depending on gestational age?

A

If less than 34 weeks, risks of prematurity outweigh risk of intrauterine sepsis (so manage conservatively).
Deliver after 34w as intrauterine sepsis greater risk than prematurity

33
Q

What are the risks of PROM?

A
  • Preterm labour
  • Chorioamnionitis
  • Umbilical cord prolapse
34
Q

When is umbilical cord prolapse likely to occur?

A

-Foetal presenting part not engaged in pelvix or fits poorly into LUS and against cervix (e.g. foot)

35
Q

What is the most suggestive sign of PROM?

A

Pool of clear fluid in the posterior fornix (can analyse for alkaline pH, amniotic fluid factors, phospholipids)

36
Q

How may membrane rupture be distinguished from urinary incontinence?

A

Give mother perineum: colours urine orange

37
Q

What must be done if conservative management of PROM is undertaken?

A

Watch chorioamnionitis:

  • cervical and urine micro
  • serial WBCs
  • CTG
  • maternal temp and pulse
  • observation of continuing liquor loss for clarity v purulence
  • appearnce of uterine tenderness
38
Q

How is PROM diagnosed?

A
  • Hx: gush of fluid, persistent leak
  • PEx: obvious liquor, cough test, pooling on spec exam
  • USS: oligo/anhydramnios
  • Amnisure
  • Take a HVS and LVS as time of examination + CRP, FBE, MSU
39
Q

What is the corticosteroid of choice in preterm foetus?

A

Betamethasone 11.4mg IM; 2 doses 24h apart

40
Q

Management if contractions of preterm labour settle?

A
  • Observation
  • Exclude treatable precipitants
  • Monitor closely for further episodes
  • If no signs of preterm labour, do not give ABx or MgSO4
41
Q

Neuroprotection mx strategy in preterm labour?

A

MgSO4:

  • 4g loading dose over 15min for imminent delivery.
  • non imminent: 4g loading dose, 2g/h maintenance
42
Q

What does MgSO4 do for foetus?

A

Foetal neuroprotection: reduces the risk of CP and gross motor dysfunction when given to women at risk of PTB.

43
Q

Describe management of preterm labour and birth

A
  • Paeds, anaesthetics, theatre available
  • IV access, FBE, G and H
  • NBM
  • MgSO4 loaded 4g/15m
  • Continuous CTG
  • Epidural anaesthetic
  • IDC
  • Syntocinon infusion on standby (40IU in 1000mL and 10U in 1000mL)
  • Active management third stage (40U syntocinon)
  • Placenta for histopath
44
Q

What are the short term problems in the neonate of preterm birth?

A
  • Resp: RDS, bronchopulmonary dysplasia, apnoea of prematurity
  • CV: PDA, hTN
  • Hypothermia
  • Hypoglycemia
  • ICH
  • Necrotising enterocolitis
  • Retinopathy of prematurity
  • Jaundice
  • Infection
45
Q

What are the long term complications of preterm birth?

A
  • Neurodevelopmental disabilities: (motor eg. CP, sensory impairment, cognitive impairment, behaviour / psych)
  • Chronic medical (growth, GIT)
  • Adult health conditions (insulin resistance, hypertension, reduced fertility)
46
Q

Which women should receive MgSO4?

A

Women less than 32w with delivery imminent within 24h

47
Q

Ix in preterm labour?

A
  • GBS
  • Urine culture
  • Drug testing if RFx (cocaine and abruption)
  • Foetal fibronectin if less than 34w and cervial dilation less than 3cm
48
Q

Mx of women 34/40+ presenting in preterm labour?

A

Admit for delivery.

  • NO CST/ Mg etc
  • Observe 4-6h
  • Exclude complications (abruption, chorioamnionitis, PROM)
  • If settles can discharge with follow up
49
Q

What are the gestational age criteria of preterm birth?

A
  • Mod- late preterm: 32-37w
  • Very preterm: 28 - 32w
  • Extremely preterm: below 28w

Women's Health (39 decks)

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